Validity and Effectiveness of Dhikr Breathing Relaxation Model Therapy on Insomnia Disorders

. Insomnia is the most common sleep disorder reported by the public, which impacts disrupting activities during the day and worsening body health. Therefore, interventions are needed to improve the quantity and quality of sleep for the body to be healthier. This study aims to analyze the content validity and the effect of applying dhikr breathing relaxation therapy on insomniacs. This research and development involved five experts/psychologists with a minimum education of a master’s in psychology and nine people with insomnia in their productive age domiciled in Surakarta as the research subjects. Insomnia subjects were chosen using the sequential-random sampling method and selected utilizing the Insomnia Severity Index (ISI). The measuring instrument used was a content validity assessment questionnaire assessed by experts (raters). The content validity analysis employed Aiken's V coefficient, and the effect of the therapy application was analyzed descriptively from qualitative data in the form of interviews a week after the therapy application on the subjects with insomnia. The validation test results obtained an average V value of 0.981. The analysis results showed that the effects of applying the therapy model, in general, had a positive influence on improving sleep quality, characterized by ease of entering sleep, reducing the frequency of awakening during sleep, and waking up refreshed. In conclusion, the dhikr breathing relaxation therapy model has a positive effect on improving sleep quality. This study implies that the dhikr breathing relaxation therapy model is appropriate and feasible to use as a therapy to reduce insomnia symptoms.


INTRODUCTION
Good quality sleep in sufficient quantities is vital for the body because it makes it healthier and can prevent the body from developing various diseases (Buysse, 2014). Quality sleep will also influence increasing work productivity, maximum body resistance, and avoiding several degenerative diseases; on the other hand, prolonged lack of sleep can weaken the body's defense system and make the body more susceptible to illness and infection (Besedovsky et al., 2019). Lack of sleep at night is a common complaint often reported. If difficulty initiating and maintaining sleep occurs for a e-ISSN: 2541-450X p-ISSN: 0854-2880Indigenous: Jurnal Ilmiah Psikologi 2022(2), 119-129 Purwanto, Anganti, & Yahman | 121 a study by de Diego-Cordore (2020), spirituality and religion have a promising role in better sleep.
Here, Islam is a religion believed by most Indonesian population, so the Islamic-based therapy application will be accepted and give a better impact. Islam also has a belief system that can be an additional element of therapy. Several studies have used Islamic beliefs to impact the therapy process (Perwataningrum et al., 2016;Soliman & Mohamed, 2013). Applying an Islamic-based therapy model for insomniacs has improved sleep quality and decreased insomnia levels (Fandiani et al., 2017;Vitaliati, 2017). Dhikr breathing is defined by Purwanto (2012) as a state of awareness about God in every inhalation and exhalation. Every breath in is accompanied by dhikr Huu, while every breath out is carried out by the heart for Allah. Considering that the breath leads to the awareness of Allah SWT, a conscious transcendent consciousness, it will be the basis for accepting everything that happens during the dhikr process. The awareness of breathing will make the subject feel breathless; awareness of everything happening in the body will also lead to acceptance of the body. On the other hand, the cause of stress is not accepting what is happening. Hence, accepting what is happening will cause the mind and emotions to relax and the body's muscles to rest. This situation can cause drowsiness in the subject (Purwanto, 2012).
The dhikr breathing method developed by Purwanto in 2012 is divided into four stages. The first stage is to sit back and be aware of breathing in and out. Next, the second stage is to continue the procedure for dhikr in the first stage, only that it is added with the pronunciation of Huu when the breath goes in and the dhikr of Allah when the breath comes out. In the third stage, when the breath goes in and dhikr Huu, there is an awareness of getting closer to Allah SWT, and when the breath comes out and dhikr Allah, awareness is brought to pleasure or surrender to Allah SWT. Finally, the fourth stage is realizing a state of awareness of surrendering and fully accepting God (Purwanto, 2012). Purwanto's (2016) research showed that dhikr breathing could be used as a therapy to improve one's sleep quality. For this reason, this study specifically aims to develop a relaxation therapy module for dhikr breathing to reduce insomnia disorders. The problem formulation in this research is: Is dhikr breathing relaxation therapy feasible to be applied as insomnia therapy? METHOD This type of research is research and development. This research is in the developing stage of a therapy model and to test the effectiveness of the therapy model of dhikr breathing relaxation on insomniacs. This module test involved five psychologists with a minimum education of master's degree and nine insomniacs. The insomnia subjects were insomniacs selected from 20-40 because this age is productive. The selection of insomnia subjects was carried out using a sequential-random sampling method, a technique in which the population is sampled sequentially. In this case, data collection and analysis were carried out at each stage. This technique was chosen because the insomnia population was relatively small and was based on certain characteristics: the presence of sleep problems, productive age, and domicile in Surakarta. Insomnia subject selection used the Insomnia Severity Index (ISI), with a Likert scale of 0-4. ISI contained seven-question items: difficulty initiating sleep, difficulty staying asleep, waking up too early, dissatisfaction with sleep, visibility of sleep disturbances by others, the influence of sleep problems on daily activities, and irritation with sleep problems.
The therapy media applied were in the form of modules and audio media (recording) of the therapy model of dhikr breathing relaxation. Before being applied to the target subjects, the module and audio media (recording) were assessed for validation by the experts (raters). The measuring instrument used was a content validity assessment questionnaire, with a Likert scale of 1-4 (1 = "Highly Not Appropriate", 2 = "Not Appropriate", 3 = " Appropriate" and 4 = "Very Appropriate"). The research application stages of the therapy model of dhikr breathing relaxation were as follows: First, research participants were obtained from the screening process using the Insomnia Severity Index (ISI) with a validity of 0.971-1 and reliability of 0.997. Second, therapy was carried out through training from ready-made modules. The training in applying this dhikr breathing relaxation model was carried out by qualified trainers: who had experience in training and had a master's degree in psychology. The trainer was not among the researchers to avoid any form of bias. The training participants received special training for a day to understand the intervention module delivered. The relaxation therapy model was applied in three training sessions: body scan relaxation, breathing relaxation, and dhikr breathing relaxation. Finally, a therapy evaluation was made after one week of therapy. The things evaluated included the implementation at home before bed, difficulties during the exercise, and the respondent's suggestions for the audio module at home.
The analysis used in this study was the validity testing of the therapy model, calculated using the Aiken's (V) coefficient formula [V= ∑S/(n(c-1))], S=r-lo; lo is the lowest score for validity (1); c is the highest score of validity assessment (5); n is the number of raters; r is the number given by the rater (Hendryadi, 2014). After obtaining the Aiken's V coefficient per assessment item in the form of a questionnaire, it was then averaged as a whole. Analysis of the therapy model application's effects used descriptive qualitative data from interviews one week after the therapy model application.

RESULTS AND DISCUSSION
The relaxation therapy model of dhikr breathing is a combination of the breathing relaxation model with dhikr, designed based on the preliminary research results regarding the discussion of the material arranged in this therapy model. Before being applied to insomniacs, it was necessary to conduct a validity assessment to evaluate the suitability of the therapy model and analyze the effects of applying the therapy model of dhikr breathing relaxation.

Validation of the therapy model of dhikr breathing relaxation
This therapy model was developed with targets for insomniacs. Before being applied to the targets, a validation test was conducted by experts to assess the suitability of the therapy model with the goals of the therapy model, the target audience, and psychological scientific materials. The scores for the therapy model of dhikr breathing relaxation were analyzed using V Aiken's coefficient validity analysis. The analysis results can be categorized as valid if they meet the limits of Aiken's V coefficient. The limit requirement of the V Aiken coefficient for four rating scales and five raters is 0.87 (p=0.021). Table 1 summarizes the validation test results for the experts' relaxation therapy model of dhikr breathing.
The validity assessment results of the therapy model of dhikr breathing relaxation showed that of the 16 items assessed, a V coefficient value of 0.933 to 1 was obtained, and overall, the therapy model had a V value of 0.981. The V coefficient results on 16 items were higher overall than the standard Aiken's coefficient of 0.87 (p = 0.021) (Aiken, 1985). Thus, it can be concluded that the therapy model of dhikr breathing relaxation was valid and feasible to be used as a therapy model. The process/stages of therapy Therapy activities are in accordance with the therapy sequence process.

Valid
The therapist's activity is in accordance with the therapy process.

Valid
Participants' activities are in accordance with the therapy process.

Analysis of the Effects of Application of Dhikr Breathing Relaxation Model Therapy
The training process was divided into three sessions. The training was guided by a competent, experienced facilitator (trainer) in psychology training (psychotherapy). Since the therapy model of dhikr breathing relaxation was applied during the pandemic, the training venue was in an open space and still observing strict health protocols. Analysis of the training effect in each session was carried out qualitatively. The facilitator gave open questions to the subject about experiences or things experienced during the training in body scan relaxation, breathing relaxation, and dhikr breathing relaxation sessions.
In the therapy module used, the first therapy session was a body scan relaxation. In the body scan relaxation session, the insomniac subjects were invited to explore all body parts to feel relaxed. The relaxed state would make it easier for the insomniac subjects to receive all the sensations in all body parts and make it easier to wake up and fall asleep. Insomnia subjects were also invited to focus on body sensations gradually from the lowest body part to the upper body part and accept these body sensations. The body scan relaxation session was 90 minutes long. A total of three subjects felt that the quality of the audio media delivered was inappropriate.
A total of nine subjects felt disturbed by the ambient sound.
A total of one subject felt disturbed by dreams.
A total of one subject felt disturbed by his sleeping position.
A total of five subjects felt sleepy during the training.
A total of two subjects fell asleep during the training.
A total of two subjects felt relaxed during the training.

Audio quality C2
There is a sound all around. D1  Table 2 summarizes the subjects' experiences during the training session of body scan relaxation. During the body scan relaxation session, some subjects felt a change in the sound of the audio media delivered; the quality of the audio media delivered was not appropriate; they were disturbed by surrounding sounds, disturbed by dreams, disturbed by sleeping position, and sleepy during training, falling asleep during training and feeling relaxed during training.
After the body relaxed with the body scan method, in the next session, the subjects were invited to relax and focus more by letting the breath. Breathing in and breath out allowed. This session is known as a breathing relaxation session. The breathing relaxation session combines relaxation methods by incorporating meditation and focusing on the breath. This session allowed the subject to feel disturbed by the surrounding environment. Subjects were invited to be aware of, accept, and let what was happening in the surrounding environment and returned to focus on their  A total of one subject felt disturbed by dreams.
A total of two subjects felt physically disturbed.
A total of two subjects felt sleepy during the training.
A total of eight subjects fell asleep during the training.
A total of five subjects felt relaxed during the training.
A total of one subject felt more aware during the training.
A total of four subjects felt relaxed during the training.
A total of one subject felt accepted the situation.  Table 3 summarizes the subjects' experiences during the breathing relaxation training session. During the breathing relaxation session, some subjects felt disturbed by the sounds around, disturbed by dreams, physically disturbed, sleepy during training, asleep, relaxed during training, feeling more aware during training, feeling relaxed during training, and feeling accepting of the situation. Furthermore, the third session, the last session of therapy, was the dhikr breathing relaxation. In this dhikr breathing relaxation session, the subjects were invited to do a comprehensive therapy, including body scan relaxation, breathing relaxation, and dhikr breathing relaxation. In this session, the subjects were also directed to be aware of and accept the breath that went in and out and was aware of the spoken dhikr sentences following each breath in and out in a relaxed manner. Here, the element of belief (dhikr) can accelerate the state of relaxation. Moreover, insomniacs often complain of not being able to sleep and making themselves stressed. The stress is caused by not accepting what is happening to oneself. Therefore, the purpose of accepting the situation was to accelerate the subjects to feel relaxed. The dhikr breathing relaxation session also lasted 90 minutes. A total of one subject felt disturbed by dreams.
A total of two subjects felt physically disturbed.
A total of two subjects felt sleepy during the training.
A total of eight subjects fell asleep during the training.
A total of five subjects felt relaxed during the training.
A total of one subject felt more aware during the training.
A total of four subjects felt relaxed during the training.
A total of one subject felt accepted the situation.  Table 4 summarizes the subjects' experience during the session training of the dhikr breathing relaxation. During the dhikr breathing relaxation session, some subjects felt disturbed by the surrounding sound, disturbed by dreams, physically disturbed, felt sleepy during training, fell asleep during training, and felt relaxed during training. The application results of the dhikr breathing therapy model, in general, had a positive effect on improving sleep quality, which can be seen from the number of subjects feeling sleepy, sleeping, and relaxed during training.

Evaluation of Subject Experience After One Week of Model Application
This evaluation aimed to assess how much influence the application had on the target subjects' sleep behavior and quality. The evaluation was carried out one week after the therapy model application and running the therapy model of dhikr breathing relaxation independently at home. The evaluation method was performed by interviewing the target subjects again by telephone. Table 5 summarizes the results of the interviews after one week of applying the therapy model of dhikr breathing relaxation. In general, in implementing the dhikr breathing relaxation practice at home for one week, the subject experienced increased sleep quality (7). It indicates that subjectively, they experienced an increase in sleep comfort. By listening to and following the audio instructions, participants experienced a process of relaxation, got a sleepy state, and could sleep. This subjective improvement in sleep quality was also characterized by ease of entering sleep (5). Following the guide of the dhikr breathing relaxation made the duration from lying down to sleep faster than usual. The second sign of improved sleep quality was waking up feeling refreshed (4). Waking up in the morning in a fresh state indicated that during sleep, respondents experienced a state of deep sleep longer than usual. A deep sleep state allowed the respondents to rest, so they woke up feeling refreshed. The third sign of increased quality sleep was reduced wakefulness during sleep (2). Waking up during sleep can cause fatigue and indicate that the sleep is not deep; one sleeps more often but wakes up easily. The emergence of many dreams during sleep is also the cause of frequent awakenings from sleep. However, the results of evaluating the effect of applying the therapy model in this study cannot be compared with other studies due to differences in the data collected. The data collected in other studies are quantitative, while in this study, the data collected are qualitative. Several studies have shown a significant correlation and influence between therapy models combining breath relaxation with dhikr meditation on sleep latency and insomnia levels. The study results (Purwanto, 2016) regarding the dhikr breathing therapy model showed a significant relationship with sleep latency. Sleep latency is the period between preparation for sleep and the onset of sleep and is the main indicator to determine a person's sleep quality (Purwanto, 2016). The results of other studies (Vitaliati, 2018) revealed the effect of religious relaxation on insomnia so that it can be used as a solution to improve insomnia conditions. Religious relaxation in research (Vitaliati, 2018) combines deep breathing relaxation with repeated chanting of "Allah" and praying accompanied by an attitude of resignation. In another study (Cahyaningtias et al., 2021), there were differences in the combination of therapy models applied. Their study (Cahyaningtias et al., 2021) investigated the effect of a combination of dhikr and progressive muscle relaxation on the insomnia level in the elderly. Their study uncovered a significant difference between the insomnia level in the elderly before and after combination therapy of dhikr and progressive muscle relaxation, with a p-value = 0.001.
One of the limitations of this study is that there was no quantitative data on the sleep quality of insomniac subjects using standard insomnia measuring instruments, so the scores of the effect's analysis before and after the application of the therapy model of dhikr breathing relaxation could not be seen statistically. In further research on the therapy model application, it is hoped that researchers can prepare supporting measuring instruments to be statistically tested for the effect of their application.

CONCLUSION
This study concludes that the therapy model of dhikr breathing relaxation had good content validity on all components, i.e., modules, audio media (recording), and trainers. The evaluation results of applying the therapy model of dhikr breathing relaxation, in general, had a positive influence on improving sleep quality, characterized by easier entering to sleep, waking up in a fresher state, and reduced awakening during sleep. Therefore, the model of dhikr breathing relaxation therapy can be used as a solution to improve one's sleep quality.